To get a clear picture of your situation and needs, we would like to ask you to answer these questions truthfully.

Only if you answer the questions honestly can we put together a suitable, safe and effective training and nutrition program for you.

So take the time to complete the intake as accurately as possible.

Questions?

There may be sensitive questions. Below we try to answer any questions about this.

How do you process this information?

Your information will not be shared with third parties at any time. Only your Personal Trainer has access to the answered questions.

Why do you want to know if my parents had certain diseases?

Because we want to have a good picture of you as a person. Any hereditary conditions can affect the program we put together for you.

What should I do if certain answers have changed during the training?

Always keep your personal trainer informed of any changes in your lifestyle and medical situation.

I don't need my doctor's permission to exercise, right?

In some cases it is wise to consult with the doctor whether a certain physical effort can lead to problems. That is why we ask the Loadability questions. We therefore recommend that you consult your doctor if you answered yes to any of these questions.

Personal information

Voornaam *

Achternaam *

Address

Postal Code

Plaats

Phone number *

E-mail *

Age *

Hoogte *

Starting weight *

Target weight *

Training target

What is your main goal? Be as specific as possible *

What has prevented you from achieving this goal so far? *

Do you see yourself as someone with discipline? *

Nee

How much time a week could you commit to personal training? *

2 sessions per week

3 sessions per week

4 sessions per week

5 sessions per week

Is there anything physical that you can’t do right now, but that you’ve always dreamed you could do? *

How do you want to feel after a training session? *

Driven to the limit

Strong and tired

Fresh & full of energy

Otherwise, namely

When you stand in front of the mirror are you happy with how your body looks? *

Nee

To envision your target body composition, is there anyone (athlete/movie star/celebrity) you would like to physically experience? *

Within what timeframe would you realistically want to achieve your goal(s)? *

8 weeks

12 á 16 weeks

6 months

12 months

Trainingslevel

Are you currently doing strength or cardio training? *

Nee

What kind of training do you do? (Multiple options possible)

Strength training/weightlifting/fitness/crossfit etc

Group classes such as HIIT/boot camp/power circuit/BBB/Les Mills

Cardio training such as running/cycling/swimming

Yoga/pilates/barre

Sporting activity such as boxing/tennis/hockey/soccer

Where do you mainly train?

Gym

Outside

At home

At what training level do you rate yourself? *

Current exercise

Tick the box that best corresponds to your daily exercise:

How active are you in daily life? *

Inactive (sitting work)

Moderately active (e.g. standing work or a lot of movement in the workplace or at home)

Active (active work and I train 1-3x a week)

Very active (active work and I exercise 3-5x a week)

What sport have you always wanted to do or would you like to pick up again?

Have you ever worked with a personal trainer before? *

Nee

Training schedule

Life is hectic, but to achieve the desired results it is still necessary to train 30-60 minutes 2 till 5 times a week.

Which part of the day suits you best? *

Morning

Afternoon

Evening

Nutritional Pattern

Everyone is different and therefore reacts differently to food. Because you are unique, you also have a unique metabolism. Your unique metabolism determines which composition of carbohydrates, proteins & fats you need for the best results.

How often do you eat meals prepared at home?

Never

1 a 3x per week

3 a 5x per week

Every day

What time do you eat your last meal? *

Which nutritional supplements do you currently use and why?

Have you ever followed a diet or nutrition program to lose weight? *

Nee

Did you achieve good results with that diet/nutrition program?

Yes, I lost several kilograms

Yes, but I very quickly gained back to the same weight as before the diet/nutrition program (or even more weight than before)

Nee

How often are your bowel movements? *

1x per 2, 3 of more days

Every day

2x or more per day

My stool is *

Normal

Thin and watery

Hard and often laborious

Very variable, sometimes hard and sometimes soft

Lifestyle

Do you work in shifts?

Nee

Sometimes

When do you normally work?

From 9-5

In the evening

I can organize my own time

Basically always

How many times a year do you travel abroad for work? *

How many times a week do you have business or social dinners?

Never

1-2x per week

2-4x per week

More than 4x per week

How often do you wake up during the night on average *

Never, I sleep like a log

1x to go to the toilet

2-4x per night

5x or more

Do you have trouble falling asleep at night? *

No, I fall asleep in 5 minutes

Do you have trouble getting up in the morning *

Yes, I don’t wake up without an alarm

Nee

Sometimes

Do you wake up tired in the morning?

Nee

What time do you usually go to bed? *

What time do you usually get up? *

Do you take medication to sleep better? *

Nee

Yes, namely

Indicate from the above what you have used in the past year and for what purpose

Injuries

Have you had one or more injuries in the past or at the moment? *

Nee

Are you currently being treated by a physiotherapist or other expert for your injury?

Nee

Yes, namely

Have you ever been injured in the past?

Nee

How long ago was this?

Medical Questions

Do you have health problems? *

Nee

Yes, namely

Have you had surgeries in your life? *

Nee

Yes, namely

Are you taking any medications that can affect training? *

Nee

Yes, namely

Do you ever lose your balance or consciousness due to dizziness? *

Nee

If so, how often and when does this happen?

Do you currently have a sports injury, or an old sports injury that we should take into account? *

Nee

Yes, namely

Load capacity

For most people, more exercise will not cause any problems, for others it may entail an increased risk. The questionnaire below is designed to identify that small group of people for whom physical exercise may be less suitable. Or for those who need medical advice regarding the type of exercise that is most suitable for them.

Has your doctor ever told you that you have a bone or joint problem, such as arthritis, that is made worse by exercise? *

Nee

Do you have high blood pressure? *

Nee

Do you have diabetes or another metabolic disorder? *

Nee

Has your doctor ever told you that you have a heart condition and that you should only exercise as recommended by your doctor? *

Nee

Have you ever felt pain in your chest when you exercise? *

Nee

Does your doctor currently prescribe medication? *

Nee

Have you ever had unusual shortness of breath at rest or with mild exertion? *

Nee

Is there a history of coronary heart disease in your family? *

Nee

Do you often feel weak, suffer from severe dizziness or sometimes lose consciousness? *

Nee

Do you currently drink more than 10 glasses of alcohol per week? *

Nee

Are you, or is there a possibility that you might be pregnant? *

Nee

Is there any good reason that hasn’t already been mentioned that would prevent you from participating in a high-intensity program? *

Nee

Yes, namely

Risk assessment

If you answered Yes to 1 or more questions of the ‘Workability Questionnaire’.
Consult your doctor by phone or in person before participating in any program that requires physical activity. Unless you’ve been in touch with your doctor recently.

Tell your doctor which questions you answered yes to. After medical evaluation has taken place, consult your doctor for advice. And ask if you are suitable for:

Unlimited physical exertion, starting slowly and gradually increasing the load.
Controlled or supervised physical exertion to meet your specific needs; at least in the initial phase.

If you answered firmly no to all questions, then you are likely to be suitable to:

Follow a progressive exercise schedule
Undergo a fitness evaluation

I answered ‘Yes’ to 1 or more questions and I have asked for medical advice and my doctor has agreed that I can exercise: *

Nee

Declarations

I declare that I want to participate in activities such as cardio exercises, strength training and stretching *

I realize that participating in these activities puts me at risk of injury and possible death *

I agree to the terms and conditions and the Privacy Statement of PT020

This is the end of the intake, thank you for your time!

We would like to remind you again to answer all questions honestly. Only then can we put together a suitable, safe and effective training and nutrition program for you.

I have answered these questions truthfully *

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Questions?

Personal information

Training target

Trainingslevel

Current exercise

Training schedule

Nutritional Pattern

Lifestyle

Injuries

Medical Questions

Load capacity

Declarations

+31 (0)20 308 6255

INFO@PT-020.NL

Intake

Questions?

Personal information

Training target

Trainingslevel

Current exercise

Training schedule

Nutritional Pattern

Lifestyle

Injuries

Medical Questions

Load capacity

Declarations

+31 (0)20 308 6255

INFO@PT-020.NL